Sleeve gastrectomy with transit bipartition: a potent intervention for metabolic syndrome and obesity. Ann Surg. 2012;256:104-110. [PMID: 22609843 DOI: 10.1097/sla.0b013e31825370c0]

Risk Factors for Type 2 Diabetes Mellitus Relapse in More Than 5-Year Follow-up After Sleeve Gastrectomy with Transit Bipartition

BACKGROUND

In some patients who achieved complete remission (CR) of type 2 diabetes mellitus (T2DM) after sleeve gastrectomy with transit bipartition (TB), T2DM relapses after a while. ABCD scoring predicts the likelihood of remission following TB. However, the factors affecting T2DM relapse are unknown.

METHODS

The data of patients with CR after TB who were followed for more than 5 years was analyzed retrospectively.

RESULTS

The median follow-up of 56 patients, 29 of whom were female (51.8%), was 71 months (range: 61 to 101). Eleven of 56 patients (19.6%) had relapse in T2DM. Patients with an ABCD score less than 4 had a significantly higher rate of relapse. Its sensitivity and specificity rates were 90.9% and 93.3%, respectively. Preoperative C-peptide level (OR 0.032 [CI 0.003-0.295], p = 0.002), LDL-cholesterol level (OR 1.025 [CI 1.005-1.045], p = 0.013), duration of T2DM (OR 1.553 [1.216-1.983], p < 0.001), ABCD score (OR 0.047 [0.006-0.361], p = 0.003), and FIB-4 index (OR 6.073 [1.496-24.656], p = 0.012) were risk factors.

CONCLUSIONS

Patients with longer durations of T2DM, higher LDL-cholesterol levels, lower C-peptide levels and ABCD scores, and worse liver fibrosis are at a higher risk of relapse after achieving initial CR of T2DM with TB.

Gastro-Jejunal Ileal Interposition with Bipartition: A Salvage Procedure for Severe Protein-Energy Malnutrition After Transit Bipartition

BACKGROUND

Intractable diarrhea or excess weight loss associated with protein-energy malnutrition (PEM) can occur after Transit Bipartition (TB). This study evaluates the effect of transposing the alimentary limb to the proximal intestines.

METHODS

Between 2017 and 2024, ten patients with malnutrition and diarrhea underwent Gastro-Jejunal Ileal Interposition (GJIB) surgery after TB. We prospectively monitored protein-energy malnutrition postoperatively and retrospectively analyzed demographic data, laboratory findings, and anthropometric measurements. Gastric transit scintigraphy was performed on symptomatic and asymptomatic patients to evaluate gastric evacuation diversity between the pylorus and the gastro-ileostomy.

RESULTS

Ten patients (male/female, 6/4) were operated on. The preoperative mean age was 49.4 ± 9.19 years. The mean body mass index (BMI) was 22.19 ± 1.13 kg/m2, the mean excess BMI loss (%EBMIL) percentage was 123.26 ± 14.85%, and the total weight loss percentage (%TWL) was 42.35 ± 0.33. Eighty percent of food passed through the gastroileostomy in all patients. The mean follow-up period was 50.56 ± 57.28 months. Postoperatively, the mean BMI increased to 28.16 ± 2.2 kg/m2 (p = 0.001), %EBMIL decreased to 79.88 ± 21.53% (p = 0.001), and %TWL decreased to 27.31 ± 10.1. Albumin levels rose from a median of 2.1 mg/dl to an average of 3.8 ± 0.78 mg/dl (p = 0.001), and stool frequency decreased from 11.56 ± 0.71 to 2.1 ± 2.12 per day (p = 0.001). The excluded bowel length percentage (Exl.B%) decreased significantly from 72.4 ± 3.18% to 12.3 ± 1.99% after conversion (p = 0.005). All patients were diabetic before and had remission after TB. Glycemic control was preserved after the conversion, with a median HbA1c of 5.4% compared to 5.8% before conversion.

CONCLUSIONS

GJIB may be a viable revision procedure for resolving PEM and related complications without compromising the metabolic benefits of the initial surgery on diabetes resolution by decreasing the Exl.B%.

Sleeve gastrectomy plus single anastomosis sleeve ileal bipartition versus sleeve gastrectomy alone: The role of bipartition

BACKGROUND

Sleeve gastrectomy (SG) with single anastomosis sleeve ileal bipartition (SASI) is a novel procedure for increasing the anti-metabolic efficacy of SG in severely people with obesity.

OBJECTIVES

This study aimed to compare 1-year results between SASI and SG, thereby assessing the role of bipartition.

SETTING

The study was conducted at the Medical University hospital.

METHODS

Between November 2021 and December 2022, 39 patients received an SG + SASI surgery, a total of 35 patients completed 1-year follow-up after the surgery. They were matched with a group of 70 patients with SG that were equal in age, sex, and body mass index (BMI). Operative risk, weight loss, and remission of comorbidities were evaluated after 12 months.

RESULTS

The operation time of the SASI group was significantly longer than the SG group (140.3 ± 22.8 vs. 114.9 ± 21.6 min; p < .001). At 12 months after surgery, the SASI group had better weight loss (total weight loss: 37.0% vs. 29.7%; p = .001) and achieved a lower BMI than SG (23.4 ± 2.6 kg/m2 vs. 24.6 ± 2.9 kg/m2; p = .046). Reduction of A1C and remission of T2D was greater in the SASI group. The SASI group had a higher reduction in uric acid, low-density lipoprotein, total cholesterol, and triglyceride levels after operation than the SG group. However, the SG group is superior to the SASI group in mean corpuscular volume, calcium, and iron levels.

CONCLUSIONS

In this study, adding an ileum bipartition to SG increases the weight loss, glycemic, and blood lipid control of SG only.

Long-Term Follow-Up After Bariatric Surgery: Key to Successful Outcomes in Obesity Management

Background/Objectives: Bariatric surgery (BS) is considered one of the most effective interventions for the treatment of obesity. To achieve optimal long-term results, continuous follow-up (FU) within a multidisciplinary treatment team is essential to ensure patient compliance and maximize the benefits of BS. However, many patients find it difficult to maintain regular FU, which can affect the quality of care and lead to postoperative complications. This review aims to highlight factors that may hinder compliance with FU after BS, examine potential causes and consequences of inadequate FU, and identify strategies to improve patient participation in long-term FU. Methods: The literature search was conducted between October 2023 and June 2024 in Medline (PubMed) and the Cochrane Library datasets. Studies were selected for their relevance to adherence to FU, multidisciplinary approaches, and long-term bariatric outcomes. Results: The pre- and postoperative period is critical for educating patients and healthcare team members about the importance of FU, addressing potential barriers (e.g., logistical, psychological, and social challenges), and highlighting the risk of relapse to obesity after surgery. The lack of a standardized FU protocol leads to differences between medical centers, further impacting patient adherence. Conclusions: Tailored and regularly updated strategies are essential to address individual patient needs and improve adherence to FU. Further research is needed to identify the specific factors that influence variability in long-term BS outcomes, highlighting the need for a patient-centered approach to obesity treatment.

Type 2 diabetes mellitus remission following laparoscopic sleeve gastrectomy and hindgut-based procedure: a retrospective multicenter study

Sleeve gastrectomy (SG) is considered the standard bariatric surgery due to its excellent outcomes. However, in patients with obesity and type 2 diabetes mellitus (T2DM), SG alone carries a high risk of metabolic failure. To achieve better metabolic results, SG can be combined with either foregut- or hindgut-based procedures, although a direct comparison between these approaches is lacking. In this retrospective study, we compared the bariatric and metabolic effects of SG (n = 20 patients) with SG associated with duodenal diversion and ileal interposition (SG-DD-II) (n = 20), SG associated with duodenal-ileal anastomosis (SADI-S) (n = 20), and SG associated with single gastro-ileal anastomosis (SASI-S) (n = 20). Patient data, including anthropometric measurements and T2DM characteristics, were extracted from our database. The evaluation criteria included weight loss (% excess weight loss), fasting glycemia (FGL), glycated hemoglobin (HbA1C) percentage, and T2DM remission rates. Our statistical analysis (p < 0.05) revealed that shortly after surgery, all procedures demonstrated acceptable outcomes in terms of weight loss and T2DM remission. However, after 3 and 5 years post-surgery, the T2DM relapse rate was significantly higher following SG alone compared to hindgut-based operations. In patients with obesity and T2DM, we recommend combining SG with a hindgut-based procedure to reduce the long-term relapse rate.

Efficacy of single anastomosis sleeve-ileal bypass in weight control and resolution of type 2 diabetes mellitus - a retrospective cohort study

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder exacerbated by obesity. Single Anastomosis Sleeve-Ileal Bypass (SASI) has emerged as a promising metabolic bariatric procedure that combines sleeve gastrectomy and ileal bypass, facilitating substantial weight loss and T2DM remission through restrictive and malabsorptive mechanisms. This study aims to evaluate the effects of SASI on T2DM remission, weight loss, and safety in one year follow-up. A retrospective cohort study analyzed 31 patients with obesity and T2DM who underwent SASI. Data collected included demographic characteristics, preoperative and postoperative BMI, HbA1c levels, and bariatric outcomes, including %TWL and T2DM changes. The mean age was 45 years, with a mean preoperative BMI of 40.7 kg/m². One year postoperatively, the mean %EWL was 85.6% and %TWL was 31.7%. T2DM remission was achieved in 24 (77.4%) patients, improvement in 4 (12.9%), and no change in 3 (9.7%). Hypertension improved in 21 (87.5%) patients, with 12 (50%) achieving remission. Significant reductions in BMI and HbA1c levels were observed (p < 0.001). Responders (R) and non-responders (NR) groups showed significant differences in postoperative BMI and %EWL (p = 0.007, p = 0.023). One patient experienced a Clavien-Dindo Grade III complication; no deaths occurred. SASI is an effective and safe procedure for treating T2DM, resulting in significant weight loss and metabolic improvements over a one-year follow-up. SASI seems to be a favorable option for T2DM management in metabolic bariatric surgery.

Comparison of the Effectiveness of Single Anastomosis Sleeve Ileal Bypass and Roux-en-Y Gastric Bypass in Obese Patients with Type 2 Diabetes

INTRODUCTION

The rapid increase in obesity and related problems has heightened the importance of obesity and metabolic surgery, resulting in a continuing search for the ideal surgical method. This study aimed to compare the effectiveness of Roux-en-Y gastric bypass (RYGB), which is the gold standard method, and the relatively newer method of single anastomosis sleeve ileal (SASI) bypass.

METHODS

The medical records of patients who underwent RYGB and SASI bypass were reviewed and compared regarding excess weight loss (EWL) and HgA1c, fasting glucose, serum iron, ferritin, hemoglobin (Hgb), and vitamin B12 levels.

RESULTS

The body mass index was significantly lower (p = 0.003), and the %EWL was significantly higher (p = 0.023) at 6 months postoperative in patients who underwent SASI bypass. Both groups had similar results at the other follow-up visits. The mean HgA1c levels at the 6- and 12-month follow-up visits were significantly lower in SASI patients (p = 0.037 and p = 0.012, respectively). At the 24-month follow-up, no difference was detected in HgA1c levels between the groups (p = 0.476). In patients who underwent RYGB, ferritin (p < 0.001), plasma iron (p = 0.001), and Hgb levels (p = 0.001) were significantly lower at 12, 24, and 12 months postoperatively, respectively.

CONCLUSION

SASI bypass is effective and comparable to RYGB in terms of EWL and metabolic control and has the advantage of not producing excluded segments and reducing nutritional deficiencies.

Novel Surgical Interventions for the Treatment of Obesity

Metabolic and bariatric surgery is widely recognized as the most effective and durable treatment for the disease of obesity and its associated comorbidities. In recent years, the field has seen significant advancements, introducing numerous innovative surgical options. This review aims to comprehensively examine these emerging surgical techniques, which have recently received endorsement from the American Society for Metabolic and Bariatric Surgery (ASMBS). Additionally, we will explore new technologies and methodologies supported by the latest scientific evidence. Our analysis will include a critical evaluation of the efficacy, safety, and long-term outcomes of these novel approaches, providing a detailed update on the current state of metabolic and bariatric surgery, highlighting key developments and their potential implications for clinical practice.

Spanish Experience with Latero-Lateral Duodeno-Ileostomy + Sleeve Gastrectomy with Magnet Anastomosis System

BACKGROUND

The partial diversion of intestinal contents facilitates achieving and maintaining weight loss and improving glycemic control in patients with obesity and with or without T2DM. The purpose of this study is to report our experience and 1-year follow-up with novel modification of SADI-S.

METHODS

This study is a part of a multicentric trial of patients that underwent primary side-to-side duodeno-ileostomy and sleeve gastrectomy (SG) with GT metabolic solutions magnetic anastomosis system. Feasibility, safety, and initial efficacy were evaluated.

RESULTS

The mean age of the patients included was 48 ± 8.75 years and the preoperative BMI was 43.32 ± 2.82 kg/m2. The complications were present in 30% of patients. The anastomosis patency was confirmed by the passage of radiological contrast under fluoroscopy at a mean of 17 days (17-29 days), and the mean expulsion time was 42 days (32-62). The mean diameter of the anastomosis after the magnet expulsion was 13.8 × 11.4 mm. The percentage of total weight lost at 1 year was 38.68 ± 8.48% (p < 0.001). The percentage of excess weight loss 82.5 ± 18.44% (p < 0.001) and improvements in glucose profiles were observed. Mean baseline HbA1c 5.77 ± 0.31% was reduced to 5.31 ± 0.26% (p < 0.024).

CONCLUSIONS

Latero-lateral duodeno-ileostomy + SG with magnetic duodenal bipartition is afeasible and reasonably safe technique and induces weight loss in patients with obesity and improvement of glycemic control. This modification could be considered as an option to standard SADI-S or as a first step in two stages procedure. However, larger studies are needed.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: #NCT05322122.

Outcomes of Single Anastomosis Sleeve Ileal (SASI) Bypass as an Alternative Procedure in Treating Obesity: An Updated Systematic Review and Meta-Analysis

PURPOSE

The Single Anastomosis Sleeve Ileal (SASI) bypass is a novel bariatric procedure that simplifies Santoro's procedure, balancing functional restriction and neuroendocrine modulation while preserving anatomy. We aim to conduct a single-arm meta-analysis of the SASI bypass to explore its moderate-term efficacy, as this might expand the available choices for surgeons to choose the best bariatric surgery that suits the patient's condition.

MATERIALS AND METHODS

We conducted a comprehensive search on PubMed, Scopus, EMBASE, and Cochrane to identify studies for the SASI bypass surgery focusing on outcomes such as %EWL, %TWL, remission rate of comorbidities, and complications. The statistical analysis was carried out using RStudio version 4.3.2. Heterogeneity was assessed using the Cochrane Q test and I2 statistics.

RESULTS

Our findings illuminate SASI's potency by undertaking a single-arm meta-analysis involving 1873 patients across 26 studies. At 12 months, we report a noteworthy % Excess Weight Loss (%EWL) (Mean 84.13; 95% CI 78.41-89.85; I2 = 95%), and % Total Weight Loss (%TWL) (Mean 35.17; 95% CI 32.30-38.04; I2 = 97%), highlighting SASI's efficacy on weight loss. Cumulative meta-analyses supported these findings. More weight loss was observed with a 250 cm common limb and a greater than 3 cm anastomosis. An 88.28% remission rate in type 2 diabetes mellitus (95% CI 79.74-95.03; I2 = 84%) at 12 months was observed. Beyond weight outcomes, SASI impacts comorbidities with a good safety profile.

CONCLUSION

Our study positions the SASI bypass as a good alternative option. However, long-term efficacy is yet to be explored in the future.

The role of metabolic and bariatric surgery on the obesity pandemic in Latin America: A review of current practices and future directions

Latin America faces a significant public health challenge due to the high prevalence of obesity and its associated diseases. Metabolic and bariatric surgery is effective and safe to treat obesity when other treatments fail; however, its implementation in Latin America remains unsatisfactory. This review explores the current status, challenges, and innovations of metabolic and bariatric surgery in Latin America. We searched peer-reviewed journals in English and Spanish for relevant articles published between 1998 and 2023. We found that more than 20% of the Latin American population is affected by obesity. Unfortunately, only a limited number of patients have access to metabolic and bariatric surgery due to high cost, limited availability, and shortage of specialists. The review found that ongoing clinical trials are being conducted in Brazil, Mexico, Chile, and Venezuela, indicating some regional progress. However, published studies remain low in number compared with other regions. Furthermore, we summarized the clinical outcomes, risks, and perioperative assessments associated with metabolic and bariatric surgery. We discussed potential strategies to enhance the availability and affordability of this intervention. This review emphasizes the significance of metabolic and bariatric surgery in addressing the obesity pandemic, specifically for Latin America, and proposes directions for future research and innovation.

Challenges in the care and treatment of patients with extreme obesity

Obesity is a prevalent chronic disease. The management of extreme obesity - i.e., body mass index (BMI) ≥ 50 kg/m2 or obesity class IV and V - is still far from ideal. Individuals with extreme obesity have a high risk of surgical complications, mortality, comorbidities, and reduced weight loss following bariatric surgery. Although lifestyle changes and anti-obesity medications are recommended for all patients with extreme obesity as adjuvants to weight loss, these measures are less effective than bariatric surgery. As a first step, sleeve gastrectomy or an inpatient very-low-calorie diet should be incentivized to enhance weight loss before definitive surgery. Although malabsorptive procedures lead to greater weight loss, they are associated with an increased risk of early complications and malnutrition. Nonstandard techniques employed in clinical trial protocols, such as transit bipartition, may be performed as they maintain a weight loss potency comparable to that of the classic duodenal switch but with fewer nutritional problems. Anatomical causes should be investigated in patients with postoperative suboptimal clinical response or recurrent weight gain. In these cases, the initiation of anti-obesity drugs, endoscopic therapies, or a conversion procedure might be recommended. More studies are needed to address the specific population of patients with extreme obesity, as their outcomes are expected to be distinct from those of patients with lower BMI.

Sleeve gastrectomy with duodenoileal bipartition using linear magnets: feasibility and safety at 1-year follow-up

BACKGROUND

Single-anastomosis metabolic/bariatric surgery procedures may lessen the incidence of anastomotic complications. This study aimed to evaluate the feasibility and safety of performing side-to-side duodenoileal (DI) bipartition using magnetic compression anastomosis (MCA). In addition, preliminary efficacy, quality of life (QoL), and distribution of food through the DI bipartition were evaluated.

METHODS

Patients with a body mass index (BMI) of ≥35.0 to 50.0 kg/m2 underwent side-to-side DI bipartition with the magnet anastomosis system (MS) with sleeve gastrectomy (SG). By endoscopic positioning, a distal magnet (250 cm proximal to the ileocecal valve) and a proximal magnet (first part of the duodenum) were aligned with laparoscopic assistance to inaugurate MCA. An isotopic study assessed transit through the bipartition.

RESULTS

Between March 14, 2022 to June 1, 2022, 10 patients (BMI of 44.2 ± 1.3 kg/m2) underwent side-to-side MS DI. In 9 of 10 patients, an SG was performed concurrently. The median operative time was 161.0 minutes (IQR, 108.0-236.0), and the median hospital stay was 3 days (IQR, 2-40). Paired magnets were expelled at a median of 43 days (IQR, 21-87). There was no device-related serious advanced event within 1 year. All anastomoses were patent with satisfactory diameters after magnet expulsion and at 1 year. Respective BMI, BMI reduction, and total weight loss were 28.9 ± 1.8 kg/m2, 15.2 ± 1.8 kg/m2, and 34.2% ± 4.1%, respectively. Of note, 70.0% of patients reported that they were very satisfied. The isotopic study found a median of 19.0% of the meal transited through the ileal loop.

CONCLUSION

Side-to-side MCA DI bipartition with SG in adults with class II to III obesity was feasible, safe, and efficient with good QoL at 1-year follow-up. Moreover, 19% of ingested food passed directly into the ileum.

Laparoscopic single anastomosis sleeve ileal bypass in the surgical management of morbid obesity: A single‐centre experience

Background

Single anastomosis sleeve ileal (SASI) bypass is a recently developed two‐step bariatric operation that involves a sleeve gastrectomy followed by a side‐to‐side sleeve‐ileal anastomosis. While the primary outcomes are promising, more evidence is required before SASI can be considered a standard bariatric procedure.

Objective

This study aims to evaluate short‐term outcomes of SASI bypass regarding safety, efficacy and complications.

Methods

This retrospective study involved the analysis of 75 patients who underwent SASI between January 2019 and January 2022. The study examined patients’ characteristics, comorbidities, surgical technique, operative details, post‐operative weight loss and complications.

Results

Of the 88 patients who underwent SASI, 13 were excluded, leaving 75 participants for analysis. The mean age was 36.9 ± 8.3 years, and the mean body mass index was 49.23 ± 5.5 kg/m2. Among the participants, 19 patients (25.3%) had diabetes and 8 patients (10.6%) had hypertension. The mean operative time was 78.42 ± 13.18 min. The mean excess weight loss percentage was 25.53 ± 3.63, 43.33 ± 8.78, 63.51 ± 10.85, 82.11 ± 11.42 and 88.95 ± 8.69 at 1, 3, 6, 12 and 24 months, respectively. The diabetic remission rate was 100%, and the hypertension remission rate was 75%. Post‐operative complications were observed in 12 patients (16%), with most being minor. Notably, two patients underwent SASI reversal to sleeve gastrectomy due to excessive weight loss, and one patient experienced weight regain in the second post‐operative year.

Conclusion

SASI bypass emerges as a straightforward and highly effective bariatric procedure, with an acceptable complication rate. It is easy to perform and revise, offering not only excellent and sustained weight loss outcomes during short‐term follow‐up but also the resolution or improvement of obesity‐associated comorbidities.

The Alarming Rate of Malnutrition after Single Anastomosis Sleeve Ileal Bypass. A single Centre Experience

BACKGROUND

Single anastomosis sleeve ileal (SASI) bypass is a modification of sleeve gastrectomy with transit bipartition (SG + TB). This study aims to assess the safety and efficacy of SASI as a primary metabolic and bariatric surgery (MBS).

METHODS

This is a retrospective case series of 30 patients who underwent SASI bypass from January to December 2021. All patients completed at least 12 months of follow-up.

RESULTS

Among the 30 patients, 93.3% were women, the mean age was 37.4 years, and the mean body mass index (BMI) was 45.6 kg/m2. The percentage of total body weight loss (TWL%) was 42.7%, the percent excess body weight loss (EWL%) was 92.7%, and the mean BMI at 12 months went from 45.6(35.2-58.4) to 25.8 kg/m2 (19.2-33.4). The obesity-associated complications remission rate was 87.5% for type 2 diabetes (T2D), 71.4% for hypertension (HTN) and 100% for obstructive sleep apnea (OSA). Thirteen patients (43.3%) had diarrhea, 7 (23.3%) had hypoalbuminemia, defined as serum albumin < 3 g/dl, and 6 (20%) underwent reversal of their index SASI. As for other nutritional issues, iron deficiency anemia was present in 21 patients (70%), while 19 patients (63.3%) had vitamin D, and 2(6.6%) had vitamin B12 deficiency.

CONCLUSION

Despite good short-term weight loss and improvement of obesity-associated complications, SASI is accompanied by high alarming malnutrition, even in short-term follow-up. Novel MBS should be judged for their long-term effects and compared to well-tested standard operations before they are used in routine clinical practice.

Approach to duodenal pathology in bariatric surgery: Transit bipartition as an option

Transit bipartition (TB) emerges as a bariatric surgery alternative to Duodenal Switch (DS), emphasizing complete intestinal access and reduced malabsorption. By directly stimulating the distal ileum, TB promotes weight loss while preserving endoscopic duodenal access. This technique enhances anorexigenic hormones, aiding in satiety and weight loss, with lower malnutrition risks than DS. TB shows favorable short-term outcomes in weight management and comorbidity reduction, serving as a simpler, less malabsorptive option than DS. Nonetheless, long-term studies are essential for comprehensive efficacy assessment.

One Anastomosis Transit Bipartition (OATB): Rational and Mid-term Outcomes

BACKGROUND

The "One-anastomosis transit bipartition" (OATB) is a promising emerging technique in the metabolic syndrome treatment.

OBJECTIVE

To demonstrate the results achieved with OATB in the first 5 years after surgery.

METHOD

Cross-sectional, retrospective study, with individuals undergoing primary OATB. Individuals included in the study were: ≥ 18 years, BMI ≥ 35 kg/m2; and excluded smoking habits, drug dependence, inflammatory bowel diseases. The data analyzed demographic, anthropometric, surgical, clinical, and nutritional.

RESULTS

Sixty eight participants, 75% women, average age 45.5 years and BMI 41 kg/m2. Associated diseases: osteoarthritis (52.9%), hypertension (48.5%) and type 2 diabetes mellitus-T2DM (39.7%). All underwent laparoscopy, without conversions. Average operative time is 122.6 ± 31.7 min, and hospital stay is 2.2 ± 0.8 days. The common channel length 27 and 41 patients with 250 cm and 300 cm respectively. We registered no intraoperative complications, 2 (2.9%) early complications, and 14 (20.6%) late complications. In the first 6 months, 94.7% (250 cm) and 88.9% (300 cm) of the patients no longer used medication for T2DM, with no statistical difference between the two groups. The incidence of nutritional disorders at any time during follow-up: hypovitaminosis D (14.7%), folate hypovitaminosis (14.7%), elevated PTH (7.4%), hypoproteinemia (5.9%) and anemia (5.9%). We found no statistically significant difference between 250 and 300 cm common channel groups.

CONCLUSION

We conclude that OATB is a safe and effective technique, demonstrating good control of T2DM and metabolic syndrome. There is a requirement to treat previous nutritional deficits. We need more long-term evidence and comparison to other surgical techniques.

Comparison of the ABCD Score's Accuracy in Predicting Remission of Type 2 Diabetes Mellitus One Year After Sleeve Gastrectomy, One Anastomosis Gastric Bypass, and Sleeve Gastrectomy with Transit Bipartition

PURPOSE

ABCD score is one of the scoring systems that predicts the probability of T2DM remission after bariatric surgery. Its success in determining T2DM remission after sleeve gastrectomy with transit bipartition (TB) has not yet been validated. The aim of this study was to evaluate the predictive value of ABCD score in TB.

MATERIALS AND METHODS

Of 438 patients with T2DM, 191 underwent sleeve gastrectomy (SG), 136 underwent one anastomosis gastric bypass (OAGB), and 111 underwent TB. Retrospective analysis of ABCD scores, 1-year postoperative remission rates, and the predictive accuracy of ABCD scores for these were conducted.

RESULTS

In the SG, OAGB, and TB groups, respectively, median ABCD scores were 7, 6, and 4, while complete remission rates were 95.3%, 84.6%, and 76.6% (p < 0.001). The area under curves (AUCs) for SG, OAGB, and TB were 0.829 (95% CI = 0.768 to 0.879, p < 0.0001), 0.801 (95% CI = 0.724 to 0.865, p < 0.0001), and 0.840 (95% CI = 0.758 to 0.902, p < 0.0001), respectively. There was no statistically significant difference between AUCs.

CONCLUSION

ABCD score predicts the probability of remission at 1-year follow-up in T2DM patients undergoing TB as accurately as in patients receiving SG or OAGB.

Sleeve gastrectomy with one anastomosis bipartition versus one anastomosis gastric bypass: A pilot study

BACKGROUND

One anastomosis gastric bypass (OAGB) is a new recognized metabolic surgery, but the problem that we cannot screen the excluded stomach is a troubling issue in China. The emergence of sleeve gastrectomy plus one anastomosis bipartition (SG + OAB) makes us see a hope to solve this problem.

OBJECTIVES

By comparing the efficacy of the two surgical methods, to evaluate whether SG + OAB surgery can solve the dilemma faced by OAGB that the excluded stomach cannot be screened.

METHODS

A retrospective study to compare the patients who underwent OAGB and SG + OAB was conducted. The main outcome measures were (1) operation risk, (2) weight loss, and (3) diabetes remission at 6 months.

RESULTS

This study was conducted in the bariatric/metabolic surgical center. From November 2021 to February 2022, a total of 30 patients with obesity who received SG + OAB surgery were recruited. Another matched 60 patients undergoing OAGB were recruited as control group. There was no difference in preoperative age (32.15 ± 9.02 vs. 34.47 ± 7.22; p = .224), female ratio (83% vs. 85%; p = .837), and BMI (36.18 ± 5.30 vs. 34.68 ± 5.58; p = .217) between the two groups. OAGB had a shorter mean operation time (121.67 ± 20.41 vs. 143.50 ± 25.07 min; p < .001) and a lower intraoperative blood loss (21.92 ± 12.35 vs. 32.43 ± 22.01 mL; p = .005), but a longer postoperative flatus passage (2.13 ± 0.43 vs. 1.87 ± 0.43 days; p = .007) compared with the SG + OAB group. Two patients (6.7%) developed major surgical complication in SG + OAB group but no major complication developed in OAGB group. At 6 months after surgery, SG + OAB had a higher %total weight loss than OAGB (31.05 ± 3.12 vs. 28.14 ± 5.43%; p = .015), but diabetes remission rate was similarly high in both groups.

CONCLUSIONS

SG + OAB operation had a non-inferior or even better weight loss than OAGB, with a similar glycemic control efficacy. However, the high complication rate of SG + OAB is the major drawback that needs attention.

Comparison of three different anastomotic methods of sleeve gastrectomy with transit bipartition using an obese rodent model

The long-term effects and safety of single-anastomosis sleeve ileal (SASI) bypass have not been confirmed. The one anastomosis procedure carries the risk of bile reflux, and Braun anastomosis has the capacity to reduce bile reflux. This study was designed to compare the influences of bile reflux and histological changes in the esogastric sections of rats. Obese Sprague-Dawley rats underwent sleeve gastrectomy with transit bipartition (RYTB) (n = 12), SASI (n = 12), SASI bypass with Braun anastomosis (BTB) (n = 12), esojejunostomy (EJ) (n = 12), and SHAM (n = 8) surgery. During the 12-week follow-up period, weight changes, glucose improvement, and changes in serum nutrition were evaluated. Histological expression and bile acid concentration in the rats in all groups were also evaluated. No significant differences in weight loss and glucose improvements were observed in the RYTB, SASI, and BTB groups. The RYTB and BTB groups had significantly lower bile acid concentration and albumin levels than the SASI group. In addition, mucosal height in the RYTB and BTB groups was significantly lower than in the SASI group. Braun anastomosis had a significant effect on anti-reflux. BTB may be a superior primary procedure due to its potential for parallel bariatric and metabolic improvements, effective anti-reflux effects, simplified operations, and avoidance of severe malnutrition. Further clinical studies are needed to confirm these findings.

BRAZILIAN MULTI-SOCIETY POSITION STATEMENT ON EMERGING BARIATRIC AND METABOLIC SURGICAL PROCEDURES

This Brazilian multi-society position statement on emerging bariatric and metabolic surgical procedures was issued by the Brazilian Society of Bariatric and Metabolic Surgery (SBCBM), the Brazilian College of Digestive Surgery (CBCD), and the Brazilian College of Surgeons (CBC). This document is the result of a Brazilian Emerging Surgeries Forum aimed at evaluating the results of surgeries that are not yet listed in the Federal Council of Medicine (CFM), the regulatory agency that oversees and regulates medical practice in Brazil. The Forum integrated more than 400 specialists and academics with extensive knowledge about bariatric and metabolic surgery, representing the three surgical societies: SBCBM, CBC, and CBCD. International speakers participated online and presented their experiences with the techniques under discussion, emphasizing the regulatory policies in their countries. The indications for surgery and the subsequent procedures were carefully reviewed, including one anastomosis gastric bypass (OAGB), single anastomosis duodeno-ileal with sleeve gastrectomy (SADI-S or OADS), sleeve gastrectomy with transit bipartition (SGTB), and sleeve gastrectomy with ileal interposition (SGII). The recommendations of this document are based on an extensive literature review and discussions among bariatric surgery specialists from the three surgical societies. We concluded that patients with a body mass index over 30 kg/m2 may be candidates for metabolic surgery in the presence of comorbidities (arterial hypertension and type 2 diabetes) with no response to clinical treatment of obesity or in the control of other associated diseases. Regarding the surgical procedures, we concluded that OAGB, OADS, and SGTB are associated with low morbidity rates, satisfactory weight loss, and resolution of obesity-related comorbidities such as diabetes and arterial hypertension. SGII was considered a good and viable promising surgical alternative technique. The recommendations of this statement aim to synchronize our societies with the sentiments and understandings of most of our members and also serve as a guide for future decisions regarding bariatric surgical procedures in our country and worldwide.

Laparoscopic Sleeve Gastrectomy With Transit Loop Bipartition and Transit Bipartition in Type 2 Diabetic Patients With Obesity: A Retrospective Analysis

AIM

We aimed to compare 1-year postoperative results of patients with obesity and type 2 diabetes mellitus (T2DM) who underwent laparoscopic sleeve gastrectomy with transit bipartition (LSG-TB) and transit loop bipartition (LSG-TLB) and mini gastric bypass (MGB).

PATIENTS AND METHODS

This is a retrospective comparison of 2 novel bariatric surgery techniques with MGB. Primary outcome measure of the study was a rate of T2DM remission. Secondary outcomes included excess body mass index (BMI) loss, improvement in hepatosteatosis, and duration of operation. Revision surgery needs were also assessed.

RESULTS

Overall, 32 patients underwent the LSG-TLB, 15 underwent LSG-TB, and 50 underwent MGB. Mean age and sex distribution were comparable for all groups. Presurgical BMI was similar in MGB and LSG + TB groups, whereas LSG + TLB group had significantly lower BMI values compared with the MGB group. In both groups, BMI values reduced significantly compared with respective baseline values. Excess BMI loss was significantly higher in patients who underwent LSG-TLB compared with patients treated with LSG-TB and MGB. Bariatric surgery procedures lasted shorter in LSG-TLB than in LSG-TB. However, the shortest of all was MGB. The remission of T2DM rates were 71% and 73.3% in LSG-TLB and LSG-TB groups, respectively ( P > 9.999). The rate of revision surgeries was comparable in both groups.

CONCLUSION

In conclusion, LSG-TLB took less time and provided significantly higher excess BMI loss compared with LSG-TB. T2DM remission and improvement rates were similar in both groups. LSG-TLB seemed like a promising bariatric surgery technique in patients with obesity and T2DM.

Safety and Efficacy of Single Anastomosis Sleeve Ileal (SASI) Bypass Surgery on Obese Patients with Type II Diabetes Mellitus during a One-Year Follow-up Period: A Single Center Cohort Study

BACKGROUND

We aimed to evaluate the safety and efficacy of single anastomosis sleeve ileal (SASI) bypass surgery on obese patients with type II diabetes mellitus during a one-year follow-up period.

METHODS

We included patients with a body mass index (BMI) more than 35 kg/m2 and at least one-year history of type II diabetes mellitus. We excluded patients aged under 25 or above 66 years, those who were not candidates for surgery, needed another bariatric surgery, and those not willing to participate in the study. All the patients were visited in the outpatient office on the 10th and 45th days as well as the 3rd month of the post-operative period until the end of the first year.

RESULTS

in this study, we investigated 14 male (23.0%) and 47 female (77.0%) morbidly obese patients with type II diabetes mellitus who underwent SASI bypass. The mean excess weight loss (%EWL) was 60.99±15.69 and the mean total weight loss (%TWL) was 30.39±6.52 at the end of the one-year follow up. Finally, 44 patients (72.1%) had a complete and 15 patients (24.6%) had partial remission of type II diabetes mellitus. Of note, severe complications were recorded in two patients (3.2%). Paired t test analysis demonstrated a significant decrease for fasting plasma sugar (FBS) after one-year follow-up in comparison with FBS before surgery (P<0.0001). Furthermore, this difference was observed in HbA1c (P<0.0001).

CONCLUSION

SASI bypass is an effective method for weight loss and controlling type II diabetes mellitus.

Unpredictable Malnutrition and Short-Term Outcomes after Single Anastomosis Sleeve Ileal (SASI) Bypass in Obese Patients

Objectives

The aim of this study is to present the clinical outcomes of SASI bypass as a treatment alternative for patients with morbid obesity.

Methods

This study was a prospective follow-up of morbidly obese patients who underwent SASI bypass at Helwan University Hospital between March 1, 2019, and March 2020. The surgical procedure involved sleeve gastrectomy, followed by the anastomosis of the ileum, which was brought and hand-sewn 4 cm length side to side with the antrum, at a distance of 250 cm from the ileocecal valve. The data collected for the study included the resolution of comorbidities, incidence of gallstones, and one-year morbidity.

Results

The mean age of the studied patients (n = 30) was 44.13 ± 8.9 years. The mean BMI of the studied patients was 47.3 ± 7.6 kg/ht2. All patients were morbidly obese for an average of 24 years. Postoperatively, 48% of the patients (n = 13) developed gallstones (GS), and the formation of GS was significantly higher in patients with longer durations of obesity (P = 0.009) and rapid weight loss. There was a significant decrease in the incidence of GS after 12 months postoperatively (P < 0.05). 63% of the patients (n = 19) had malnutrition, and 15 cases required revision due to the fear of further weight loss. Revision and malnutrition were significantly higher among male patients than female patients and among patients with longer durations of obesity (P ≤ 0.001).

Conclusion

The SASI bypass may be an effective bariatric and metabolic surgery that can achieve satisfactory weight loss and improvement in medical comorbidities. However, our study highlights the potential risks of severe malnutrition and unpredictable weight loss; patient selection and duration of obesity may play a role in mitigating these risks.

Mid-term outcomes after single anastomosis sleeve ileal (SASI) bypass in treatment of morbid obesity

BACKGROUND

According to several short-term studies, single-anastomosis sleeve ileal (SASI) bypass offers similar weight loss to Roux-en-Y Gastric Bypass (RYGB) with fewer complication and better comorbidity reduction/resolution. Long-term data on this operation is lacking in the literature. The purpose of this study was to analyze the outcomes of SASI bypass up to 4 years.

METHODS

This study is a retrospective cohort analysis of 366 patients with morbid obesity who underwent primary SASI bypass from January 2018 to February 2022.

RESULTS

The mean age and preoperative body mass index (BMI) were 41 years (range 22-71 years) and 43.9 ± 6.5 kg/m², respectively. Follow-up was available for 229 patients at 1-year (89%), 112 patients at 2-year (75%), 61 patients at 3-year (75%), and 35 patients at 4-year (71%). The intraoperative, short-term, and long-term complication rates were 0%, 2.5%, 4.6%, respectively. After 4 years, mean percentage excess weight loss (%EWL) was 93.3% and total weight loss (%TWL) was 41.2%. Remission of comorbidities was 93% for type 2 diabetes mellitus, 73% for hypertension, 83% for hyperlipidemia, 79% for sleep apnea, and 25% for gastroesophageal reflux disease (GERD). Biliary gastritis and ulcers are seldom. Eight patients developed de novo GERD symptoms requiring proton pump inhibitor treatment. None of the patients in our study had hypoalbuminemia or malabsorption that did not respond to increased protein intake and vitamin or mineral supplementation.

CONCLUSION

SASI bypass appears to be safe, and one of the most effective bariatric procedures regarding weight loss and obesity related comorbidities. The double-outlet created in this procedure seemingly minimizes nutritional complications.

From Our One Anastomosis Gastric Bypass (OAGB) Experience to Establishing Single Anastomosis Sleeve Ileal (SASI) Bypass Procedure: A Single-Center Report

BACKGROUND

Bariatric surgery has been proven to be the most effective treatment for obesity with or without metabolic syndrome. One anastomosis gastric bypass (OAGB) is a well-established bariatric procedure developed over the past 20 years with excellent outcomes. Single anastomosis sleeve ileal (SASI) bypass is introduced as a novel bariatric and metabolic procedure. There is some similarity between these two operations. This study aimed to present our SASI procedure based on the past experience of the OAGB in our center.

METHOD

Thirty patients with obesity underwent SASI surgery from March 2021 to June 2022. Herein, we demonstrated our techniques step by step and key points of techniques learned from our experience with OAGB (shown in the video) with satisfying surgical outcomes. The clinical characteristics, peri-operative variables, and short-term outcomes were reviewed.

RESULTS

There was no case of conversion to open surgery. The mean operative time, volume of blood loss, and hospital stay were 135.2 ± 39.2 min, 16.5 ± 6.2 mL, and 3.6 ± 0.8 days, respectively. There is no postoperative leakage, bleeding, or mortality. The percentage of total weight loss and excess weight loss at 6 months were 31.2 ± 6.5 and 75.3 ± 14.9, respectively. Improvement in type 2 diabetes (11/11, 100%), hypertension (14/26, 53.8%), dyslipidemia (16/21, 76.2%), and obstructive sleep apnea (9/11, 81.8%) were observed at 6 months after surgery.

CONCLUSION

Our experience showed that our proposed SASI technique is feasible and may help surgeons perform this promising bariatric procedure without encountering many obstacles.

Analysis of the Efficacy and the Long-term Metabolic and Nutritional Status of Sleeve Gastrectomy with Transit Bipartition Compared to Roux-en-Y Gastric Bypass in Obese Rats

PURPOSE

Sleeve gastrectomy with transit bipartition (SG-TB) could be an attractive alternative to Roux-en-Y gastric bypass (RYGB) on weight loss and improvement of comorbidities in patients with obesity. However, there is little long-term data. Translational research on a rat model could allow long-term projection to assess efficacy and safety of SG-TB. The aim of this research was to evaluate the long-term efficacy and safety of SG-TB compared to RYGB and SHAM in rat model.

MATERIALS AND METHODS

Ninety-four male obese Wistar rats were distributed into 3 groups: SG-TB (n = 34), RYGB (n = 32), and SHAM (control group, n = 28). The percentage of total weight loss (%TWL), coprocalorimetry, glucose and insulin tolerance test, insulin, GLP-1, PYY, and GIP before and after surgery were assessed. The animals were followed over 6 months (equivalent to 16 years in humans).

RESULTS

At 6 months, %TWL was significantly greater(p = 0.025) in the SG-TB group compared to the RYGB group. There was no difference between the groups (p = 0.86) in malabsorption 15 and 120 days postoperatively. Glucose tolerance was significantly improved (p = 0.03) in the SG-TB and RYGB groups compared to the preoperative state. Insulin secretion, at 3 months, was significantly more important in the SG-TB group (p = 0.0003), compared to the RYGB and SHAM groups. GLP-1 secretion was significantly increased in the SG-TB and RYGB groups compared to the preoperative state (p = 0.001) but similar between SG-TB and RYGB animals (p = 0.72).

CONCLUSION

In a rat model, at long term compared to RYGB, SG-TB provides greater and better-maintained weight loss and an increased insulin secretion without impairing nutritional status.

Innovative Bariatric Procedures and Ethics in Bariatric Surgery: the IFSO Position Statement

With the rise in obesity and bariatric procedures worldwide, there has been a surge in new and innovative procedures that has been increasingly offered to patients. In this position statement, IFSO highlights the importance of surgical ethics in innovation and when offering new procedures. Furthermore, the task force reviewed the current literature to describe which procedures can be offered as mainstream outside research protocols versus those that are still investigational and need further data.

Optimal Length of Biliopancreatic Limb in Single Anastomosis Sleeve Gastrointestinal Bypass for Treatment of Severe Obesity: Efficacy and Concerns

PURPOSE

The present study aimed to compare two newly introduced procedures, single anastomosis sleeve jejunal (SASJ) with ileal (SASI) bypass in terms of weight loss, remission of obesity-associated medical problems, complications, and nutritional status.

MATERIALS AND METHODS

This retrospective study was carried out with 162 patients who underwent single anastomosis sleeve gastrointestinal bypass from October 2017 to September 2021, either single anastomosis sleeve jejunal bypass (SASJ) or single anastomosis sleeve ileal bypass (SASI). The main outcome measures were weight loss and improvement in obesity-associated medical problems, nutritional status, and complications at 12 months post-surgery.

RESULTS

At 12 months, both groups showed significant weight loss and remission in obesity-associated medical problems. There were significant differences in body mass index (BMI), total weight loss (TWL), and excess weight loss (EWL) between SASI and SASJ bypass (P < 0.05). Improvements in associated medical problems after the two procedures were similar except for hypertension. The reversal surgery rate of the SASI group was significantly higher than that of the SASJ group (5.5% vs. 0.0%, p = 0.03).

CONCLUSIONS

SASJ and SASI bypass achieved satisfactory weight loss and improvement in obesity-associated medical problems that were comparable between the two groups. SASI bypass was followed by a significant difference in the rate of reversal surgery at 1 year due to a short common channel, which was not observed after SASJ bypass.

Single anastomosis sleeve jejunal (SAS-J) bypass as a treatment for morbid obesity, technique and review of 1986 cases and 6 Years follow-up. Retrospective cohort

BACKGROUND

Santoro's operation is a sleeve gastrectomy with transit bipartition. The operation aims to maintain passage to the duodenum to minimize nutritional deficiency. This procedure is rapidly changed to single anastomosis sleeve ileal (SASI) bypass. SAS-J bypass is a modification of SASI with a short biliary limb.

MATERIAL AND METHODS

This study is a retrospective study of prospectively collected data. The study includes a comprehensive review of 1986 patients who underwent SAS-J bypass over 6 years. The total number is used to evaluate the perioperative data. One- and two-year follow-up was used to evaluate weight loss and comorbidities; follow-up of more than 5 years was used to obtain long-term results.

RESULTS

In this study, 70.4% of patients were female and 29.6% were male. The mean body mass index (BMI) was 44.7. The mean age was 42 years. Regarding comorbidities, 25.8% of the patients had type 2 diabetes, 31% were hypertensive, 14.2% had sleep apnea syndrome, 6.6% had gastroesophageal reflux disease (GERD), and 39.6% had hyperlipidemia. Of the 1294 patients who complete one-year follow up, %EWL reached 87%. Blood glucose levels were normalized in 98.5% of patients, hypertension remitted in 93%, hyperlipidemia improved in 97%, SAS is improved in all cases, and GERD improved in 89% of patients. After 5 years, 94 patients' BMI decreased from 44.3 to 28.3 without significant nutritional deficiency.

CONCLUSIONS

Laparoscopic SAS-J bypass is an effective and simple alternative bariatric procedure at short- and long-term follow-up.

Bariatric Surgery and Osteoporosis

It has been increasingly acknowledged that bariatric surgery adversely affects skeletal health. After bariatric surgery, the extent of high-turnover bone loss is much greater than what would be expected in the absence of a severe skeletal insult. Patients also experience a significant deterioration in bone microarchitecture and strength. There is now a growing body of evidence that suggests an association between bariatric surgery and higher fracture risk. Although the mechanisms underlying the high-turnover bone loss and increase in fracture risk after bariatric surgery are not fully understood, many factors seem to be involved. The usual suspects are nutritional factors and mechanical unloading, and the roles of gut hormones, adipokines, and bone marrow adiposity should be investigated further. Roux-en-Y gastric bypass (RYGB) was once the most commonly performed bariatric procedure worldwide, but sleeve gastrectomy (SG) has now become the predominant bariatric procedure. Accumulating evidence suggests that RYGB is associated with a greater reduction in BMD, a greater increase in markers of bone turnover, and a higher risk of fracture than SG. These findings should be taken into consideration in determining the most appropriate bariatric procedure for patients, especially those at higher fracture risk. Before and after all bariatric procedures, sufficient calcium, vitamin D and protein intake, and adequate physical activity, are needed to counteract negative impacts on bone. There are no studies to date that have evaluated the effect of osteoporosis treatment on high-turnover bone loss after bariatric surgery. However, in patients with a diagnosis of osteoporosis, anti-resorptive agents may be considered.

Twisted Gastric Tube after Laparoscopic Sleeve Gastrectomy-An Unusual but Effective Surgical Approach to Achieve Full Recovery

Sleeve gastrectomy is at present the most practiced bariatric intervention for patients suffering from severe obesity. Although rare, post-operative complications such as leakages and strictures may represent a challenging issue for bariatric surgeons and cause impaired quality of life for patients. Gastric twist is even more rare. This complication is a functional obstruction rather than a stricture of the gastric remnant most likely due to technical mistakes at index surgery. If endoscopy usually allows diagnosis and constitutes the first-line treatment for this condition, surgery is mandatory when endoscopy is not successful. The conversion of the sleeve to a Roux-en-Y gastric bypass is the usually chosen intervention but a wide range of reconstruction has been proposed. In this report, we discuss the surgical technique we employed to achieve a full resolution of a gastric twist.

Laparoscopic Single Anastomosis Sleeve Ileal Bypass with Follow-up of Weight Loss and Metabolic Impact

Background: Bariatric surgery has been an effective safe management for severe obesity. The newly developed single-anastomosis sleeve ileal (SASI) bypass has shown efficacy as a functional as well as mechanical restrictive bariatric procedure, with a neuroendocrine modulation effect. SASI bypass is still an investigational procedure, hence, more evidence is needed till it is declared as a standard bariatric procedure by the IFSO. Aim of the study: The current work aimed to describe our experience regarding the technical steps, the efficacy and the short-term outcome of SASI bypass procedure in patients with severe obesity. Patients and methods: Forty seven patients with severe obesity underwent SASI bypass procedure. They were followed till 1 year postoperatively. The weight loss, comorbidities and laboratory changes were assessed. Results: Patients evaluation at the 1-year postoperative follow up revealed a mean %TWL of 37.55 ± 6.17 and a mean %EBWL of 76.21 ± 9.8. The remission rates of T2DM, hyperlipidemia and hypertension were 85.7%, 94.7% and 89.66%, respectively, with statistically high significant differences between the preoperative and 1-year postoperative comorbidities rate. Stepwise regression analysis demonstrated that only the preoperative HbA1C remained in the model predicting the %TWL, and the preoperative BMI was the remaining factor in the model predicting the %EBWL in the study patients. Conclusion: The present study adds a new evidence to the promising outcome of the newly introduced SASI bypass procedure. After one year, the study patients showed excellent weight loss and comorbidities remission together with acceptable major complication rates.

Medium-term complications in patients undergoing gastric bypass

OBJECTIVE

To present our experience in the clinical follow-up of patients undergoing a gastric bypass.

METHOD

Description of six cases under follow-up by our unit after undergoing a gastric bypass at another private centre.

RESULTS

The 6 patients presented complications, the most notable being the death of one patient due to severe malnutrition and the need for revision surgery in another for the same reason, destabilisation of type 1 diabetes mellitus in another patient and fat-soluble vitamin deficiency in all of them.

CONCLUSIONS

There are few publications that support the safety of gastric bypass as a treatment for obesity. In our experience, it is a technique associated with a high rate of serious complications. As it is a technique that is not yet standardised, we consider that these cases should be operated on in centres where there is a multidisciplinary team with expertise in the management of possible complications, with close follow-up by surgeons and endocrinologists.

The Protective Effect of Transit Bipartition and Its Modification Against Sleeve Gastrectomy-Related Esophagitis in a Rodent Model

BACKGROUND

The protective effect of transit bipartition against esophagitis has not yet been proven. Thus, we investigate and compare the bariatric outcomes and esophagus' histological changes of sleeve gastrectomy (SG), SG with transit bipartition (SG-TB), and the proximal SG-TB (SG-PTB) in a rodent model.

METHODS

This study included 45 diabetic Sprague-Dawley rats assigned to one of the four groups, SG-PTB (n = 15), SG-TB (n = 12), SG (n = 10), and SHAM (n = 8). Eight surviving rats from each group were included for further investigation. Histological analysis of the gastroesophageal junction was performed. Body weight, food intake, glucose control, and hormonal changes (glucagon-like peptide-1 and insulin) were assessed before and after surgery in all groups.

RESULTS

Preoperatively, no significant differences were observed in food intake, body weight, and fasting blood glucose levels among the groups. Postoperatively, the SG-PTB and SG-TB groups showed significantly superior glucose control compared to the SG group following the gavage of glucose (p < 0.05). Postoperatively, the SG-PTB and SG-TB groups had higher postoperative GLP-1 levels than postoperative SG and SHAM groups. More severe esophageal hyperpapillomatosis (EHP) of the esophageal section was observed in the SG group. The mucosal height of the SG group was significantly higher than that of the SG-PTB, SG-TB, and SHAM groups (p < 0.05).

CONCLUSION

The transit bipartition procedure may protect the distal esophagus from histological changes associated with esophagitis. Clinical studies are needed to confirm the anti-reflux effects of transit bipartition.

Comparison of the Outcomes of Single Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADI-S), Single Anastomosis Sleeve Ileal (SASI) Bypass with Sleeve Gastrectomy, and Sleeve Gastrectomy Using a Rodent Model with Diabetes

OBJECTIVE

Single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is a powerful form of bariatric surgery; however, it has a high risk of malnutrition. Single anastomosis sleeve ileal (SASI) bypass with sleeve gastrectomy may be used as an alternative procedure to avoid malnutrition associated with SADI-S; however, no comparison between the two procedures has been performed.

METHODS

Sprague-Dawley rats with diabetes (n = 32) were divided into four groups: SADI-S (n = 8), SASI (n = 8), SG (n = 8), and SHAM (n = 8). Body weight, food intake, and fasting blood glucose were measured, and the oral glucose tolerance test (OGTT) and insulin tolerance test (ITT) were performed before and after surgery. Blood samples were collected before and after the surgery to assess the levels of glucagon-like peptide-1 (GLP-1), hemoglobin, albumin, vitamin B12, calcium, and iron.

RESULTS

The SADI-S and SASI groups showed significantly greater weight loss and better glucose control than the SG group postoperatively. The SADI-S and SASI groups showed similar improvements in glucose control throughout the study. The SADI-S and SASI groups had significantly higher GLP-1 levels than the SG group at 6 months. The SADI-S and SASI groups presented with various degrees of deficiencies, with the SADI-S group showing a higher risk for hypoalbuminemia and iron deficiency than the SASI group.

CONCLUSIONS

The SASI procedure may be a better alternative as it has excellent bariatric and metabolic results with lower risk for hypoalbuminemia and can be easily converted into either SADI-S or SG procedures. Nevertheless, further clinical results are needed.

Testosterone Changes in Men With Obesity and Type 2 Diabetes 6 Months After Sleeve Gastrectomy With Transit Bipartition

BACKGROUND

Metabolic/bariatric surgery has been shown to increase testosterone in males with obesity. This study investigated the effect of the novel metabolic/bariatric surgery procedure, sleeve gastrectomy with transit bipartition (SG-TB), on serum total testosterone and metabolic variable changes in men with obesity and type 2 diabetes.

METHODS

In a prospective single-center cohort study, laboratory samples were analyzed preoperatively and at 6 months following SG-TB in patients with a body mass index (BMI) ≥30 kg/m2. Changes in metabolic parameters and testosterone were evaluated.

RESULTS

Between July 2018 and March 2019, 166 patients with a mean baseline BMI of 34.9±3.8 kg/m2 (mean age 51.5±9.3 y), glycosylated hemoglobin 9.5±1.3%, and testosterone 3.1±1.3 underwent SG-TB. At 6-month follow-up, mean excess BMI loss was 70.2±24.3%; glycosylated hemoglobin, 6.6±1.1% (P<0.001); and testosterone, 4.5±1.5 (P<0.001).

CONCLUSION

In the early term following SG-TB, more than any other factor assessed, BMI loss was found to be a significant driver of improvement in testosterone levels. Regardless of preoperative obesity classification, patients with initially low testosterone attained significantly increased testosterone levels at 6-month follow-up.

Can we abandon foregut exclusion for an ideal and safe metabolic surgery?

Foregut (foregut exclusions) and hindgut (rapid transit of nutrients to the distal intestine) theories are the most commonly used explanations for the metabolic improvements observed after metabolic surgeries. However, several procedures that do not comprise duodenal exclusions, such as sleeve with jejunojejunal bypass, ileal interposition, and transit bipartition and sleeve gastrectomy were found to have similar diabetes remission rates when compared with duodenal exclusion procedures, such as gastric bypass, biliopancreatic diversion with duodenal switch, and diverted sleeve with ileal interposition. Moreover, the complete exclusion of the proximal intestine could result in the malabsorption of several important micronutrients. This article reviews commonly performed procedures, with and without foregut exclusion, to better comprehend whether there is a critical need to include foregut exclusion in metabolic surgery.

Short-term Results of Transit Bipartition to Promote Weight Loss After Laparoscopic Sleeve Gastrectomy

Objective

To evaluate (1) the efficacy of transit bipartition (TB) as revisional bariatric surgery (RBS) after laparoscopic sleeve gastrectomy (LSG); (2) the impact of the length of the common channel (CC) on weight loss.

Background

LSG in combination with TB has been shown to be highly efficacious for treating morbid obesity. The role of TB as RBS to address the problem of primary failure or weight recidivism after LSG is less well defined.

Methods

Observational study of outcomes in 100 morbidly obese patients who received a TB following LSG. Follow-up examinations (FE) were performed at 1, 3, 6, and 12 months. Variables analyzed included BMI, percent excess weight loss (%EWL), total body weight loss (%TBWL), effect on obesity-related conditions and complications.

Results

The mean BMI before LSG was 49.9 ± 8.5 kg/m2. A nadir of 32.7 ± 6.1 kg/m2 was reached 22.1 ± 16.9 months after LSG (%EWL 70.0 ± 14.5). The time interval between LSG and TB was 52.2 ± 26.6 months at which the BMI had increased to 37.6 ± 7.1 kg/m2 and %EWL decreased to 49.4 ± 19.7. Following TB, the BMI decreased continuously to 31.4 ± 5.7 kg/m2 after 12 months with a parallel increase in %EWL to 74.7 ± 20.3 and %TWL reaching 36.3 ± 10.5. Weight loss was significantly higher for CC length of 250 versus 300 cm after 12 months (BMI 29.4 ± 5.3/33 ± 5.3 kg/m2, P = 0.002; %EWL 79.8 ± 26.6/70.4 ± 17; P = 0.009). Improvement of comorbidities was observed in a high proportion of patients. Major early complications occurred in 3% of the patients.

Conclusion

TB is an effective second-step procedure to address insufficient weight loss or weight recidivism after LSG. CC length of 250 versus 300 cm had a significant impact. While most improvements of obesity-related comorbidities are likely linked to weight loss, amelioration of GERD is largely mediated by accelerated gastric emptying. Major complications were observed in 3% of patients and managed without fatalities.

Sleeve Gastrectomy with Braun Anastomosis Transit Bipartition (B-TB): a Potential Midway Between Single Anastomosis and Roux-en-Y Transit Bipartition

PURPOSE

The single anastomosis sleeve ileal bypass (SASI) procedure is a simple modification of the Roux-en-Y transit bipartition (RYTB) procedure; however, SASI risks patients with possible biliary reflux. Braun anastomosis has been proposed to fix the biliary reflux of single anastomosis procedures. This study presented our early "sleeve gastrectomy with Braun anastomosis Transit Bipartition" (B-TB) outcomes.

MATERIALS AND METHODS

Patients who underwent B-TB or RYTB between June 2020 and April 2021 at our hospital and have completed three months follow-up were included in this study.

RESULTS

Ten patients with B-TB and forty patients with RYTB were included. No significant differences were observed between the B-TB and RYTB patients regarding the preoperative conditions. The B-TB procedure had significantly shorter operation time and postoperative hospitalization time than the RYTB procedure. There was no significant difference between the two groups regarding the 3-month percentage of total weight loss (B-TB vs RYTB: 19.7 ± 2.7% vs 22.2 ± 5.4%) and the postoperative complications before discharge. Preoperatively, two patients and eight patients achieved GERD-Q score ≥8 for the B-TB and RYTB group, respectively. At postoperative 3 months, those with GERD-Q score ≥8 was reduced to one patient and two patients for the B-TB and RYTB group, respectively. No patients have reported symptoms of greenish-yellow vomiting in both groups postoperatively.

CONCLUSION

B-TB is an exciting procedure with potential benefits. However, as it is an investigational procedure, extra care should be maintained. Larger samples and more extended follow-up data are needed in the future.

Sleeve gastrectomy with transit bipartition in a series of 883 patients with mild obesity: early effectiveness and safety outcomes

BACKGROUND

At least 25 metabolic/bariatric procedures have been proposed globally, 5 formally endorsed. A newer procedure, sleeve gastrectomy with transit bipartition (SG + TB), appears to markedly reduce weight and improve metabolic syndrome while being relatively simple technically and protective of long-term nutritional stability. We aimed to investigate SG + TB effectiveness and safety.

METHODS

In a single-center retrospective analysis of prospectively collected data, SG + TB patients were followed through 12 months. Primary outcomes were changes in weight [body mass index (BMI), total weight loss (TWL)], metabolic parameters [HbA1_C, LDL cholesterol, triglycerides (TG), hypertension], and nutritional status. Repeated-measures analysis of variance (ANOVA) was used to assess changes in weight and metabolic parameters at 1, 3, 6, 9, and 12 months after surgery.

RESULTS

Between 2015 and 2019, 883 patients (mean age 51.8 yrs, BMI 34.1 ± 5.0 kg/m²) underwent SG + TB. Mean operative time was 124 ± 25.4 min; hospitalization, 4.0 ± 2.5 days. ANOVA indicated significant reductions in weight and metabolic parameters (p < 0.005). In 646 patients with complete weight data at 12 months, mean BMI was reduced to 27.2 ± 3.4 kg/m² (p < 0.001), TWL 19.8 ± 6.0%. HbA1_C was normalized in 83.3% of SG + TB patients; hyperlipidemia, hypertension, and hypertriglyceridemia were significantly reduced (p < 0.001). Also, there was a significant reduction in the proportion of patients outside normal nutritional reference ranges. The overall complication rate was 10.2%. There was no mortality.

CONCLUSION

In a series of 833 lower-BMI patients who underwent SG + TB and were followed through 12 months (73.2% follow-up), significant weight loss, comorbidity reduction, and nutritional stability were attained with few major complications and no mortality.

Medium-term complications in patients undergoing gastric bypass

OBJECTIVE

To present our experience in the clinical follow-up of patients undergoing a gastric bypass.

METHOD

Description of six cases under follow-up by our unit after undergoing a gastric bypass at another private centre.

RESULTS

The 6 patients presented complications, the most notable being the death of one patient due to severe malnutrition and the need for revision surgery in another for the same reason, destabilisation of type 1 diabetes mellitus in another patient and fat-soluble vitamin deficiency in all of them.

CONCLUSIONS

There are few publications that support the safety of gastric bypass as a treatment for obesity. In our experience, it is a technique associated with a high rate of serious complications. As it is a technique that is not yet standardised, we consider that these cases should be operated on in centres where there is a multidisciplinary team with expertise in the management of possible complications, with close follow-up by surgeons and endocrinologists.

Roux-en-Y Gastric Bypass with Long Biliopancreatic Limb Compared to Single Anastomosis Sleeve Ileal (SASI) Bypass in Treatment of Morbid Obesity

PURPOSE

Bariatric surgery is the most effective treatment of morbid obesity. Bariatric procedures employ different mechanisms of action to induce weight loss. The present study aimed to compare single-anastomosis sleeve ileal (SASI) bypass and roux-en-Y gastric bypass RYGB with long biliopancreatic limb (BPL) in terms of weight loss, remission of comorbidities, complications, and nutritional status.

METHODS

This was a single-center cohort study on patients with morbid obesity who underwent RYGB with long BPL of 150 cm or SASI bypass. The main outcome measures were weight loss and improvement in comorbidities at 12 months, nutritional status, and complications.

RESULTS

The present study included 92 patients (59.8% females) of a mean age of 38.4 years and mean BMI of 42 kg/m2. RYGB and SASI bypass were followed by a significant decrease in body mass index at 12 months and were comparable in terms of excess and total weight loss. Improvement in comorbidities after the two procedures was similar. The serum albumin levels showed a significant decline after RYGB, but not after SASI bypass. The postoperative serum iron levels were higher after SASI bypass than after RYGB. There was no significant difference in regard to complication rates (13% vs 4.3%, p = 0.27).

CONCLUSIONS

RYGB with long BPL and SASI bypass achieved satisfactory weight loss and improvement in comorbidities that were comparable among the two groups. Long BPL RYGB was followed by a significant decrease in serum albumin and iron levels at one year, which was not observed after SASI bypass.